Sunday, March 21, 2021

When Dr's kill patients

I'm so very sad to say that one of my patients died because of physician negligence, this is their story...

I had a patient return to our unit after getting several heart stents.  I got this patient 5 hours after they returned.

I worked night shift and the report I got was this:

Such and such a year old person, full code, just returned from getting several stents. Have been busy because said patient is having diarrhea. A&Ox3, no neuro issues. NSR, BP stable. Pt is SOB (which I interjected and asked if the SOB was new or not, did it improve at all post stents, is it worse with exertion, is the pt SOB with rest) - to which the person giving said report was unsure about some of the answers and so we stopped report so that they could give me these answers. Then we continued with report - I was told that the patient had diarrhea, has had it since admission, CDiff pending. I get told that pt has a foley and output for last 5 hrs was 150cc total, and that the pt got a dose of Lasix upon returning from the other hospital. I again interjected and commented that that is the bare minimum for the pt to have.... and that means that the patient didn't diurese at all, and that is something that should have been told to the physician before they went off duty. I asked if blood work was done upon returning and they said that it was, and find out that the patient's creatinine is sitting at 262 - and am told that the patient's baseline is in the 200's. The nurse basically said, oops, my bad.... and we completed report.

Now, I don't know about you folks but we are doing team nursing and so I got report on all but because there were other patients who were worse off and I had a cardiology nurse who was redeployed to be my "team nursing" person, I made this patient their focus....

Now fast forward a couple of hours and the redeployed nurse came to me to give report for their break and they proceed to tell me in passing that the patient's urine output "isn't too great".... which I made them give me a definitive u/o per hour - and when I'm told 10-15cc/hr I asked for how long that's been the case and I was told basically since we started shift. I was miffed to say the least and told them that they needed to now call the on-call MRP and advise them of everything.

While waiting for the MRP to call back, we looked up the blood work from before going to the other hospital and getting the stents done, and compare it to what it is upon returning..... to find out that creatinine rose from 97 to 262 and GFR (how well the kidneys are filtering) went from 40 to 15.... so ya not good!

When the MRP called back, the other nurse told em everything and the Doc asked, well how is the BP and oxygen requirements - MRP is advised that BP is stable and O2 requirements haven't changed and so is told that "it's a days issue" and completes the call. I told the other nurse to document the crap out of that (they were shocked I told them to do this, but advised them that that way if anything bad happens because of their decision, that it's on their license and not ours!) and they go and document said call. I then take over care of the patient and when I went to go tip the urometer to see the hourly u/o I find out that the patient doesn't even have a urometer.... so how in the hell is everyone checking the hourly output, I doubt that they are emptying the bag every time and measuring it. So I proceed to swapping it out for a urometer so that I can actually know an accurate hourly output.

I do my 0600hr blood work and the results show that creatinine is up to 403 and GFR is down to 9 - and the hourly u/o is <5cc/hr - so I call the MRP again and advise him of this. I get asked what the BP is and O2 requirements. I advise him that they haven't changed yet but asked if there was anything that they wanted done. I'm told again that it's a "days issue" and they could deal with it on the day shift. I commented that isn't there something that we should be doing now. I'm told, "well they could try a dose of Lasix" - I responded with "well we already tried that and there was no response, the patient didn't diurese when the patient got back from the other hospital" then the Doc said "well they could try some fluid" and I told him that the patient's already SOB and overloaded and her BNP was 4000+ and so more fluid when she wasn't making any urine was probably  not going to help. I got shot down and am told that this could be dealt with by the days MRP. And the call was ended.

When the next nurse came onto shift - same nurse that gave me report.... I told her all that had transpired and what she had screwed up. The nurse felt bad for not catching the errors of her way and doing something to fix it. I told the nurse that the patient needed a STAT nephro consult and if the MRP  wasn't on unit by 10am to call them and advise them what was happening.... then I go off shift after finishing report.

I come back for my second night shift and as soon as i'm on the unit the patient is being packed up to go somewhere.... come to find out that nephro had only shown up at like 1800/1900hr and had ordered a STAT kidney u/s and so off the current nurse and I go and I get report while we head out. She goes on to tell me that the MRP did not arrive before 10am and had to get a hold of her. Then the Doc goes and gives the nurse a hell of a time because she wasn't informed what was going on with the patient. I told the nurse not to fret about it because that wasn't her fault overnight because that's on the other Doc - she shouldn't be getting upset with her because the other Doc didn't call her and advise her what was going on with her patient overnight. I get told that nephro did come onto the unit and the nurse did try to get him to see the patient but wouldn't listen to the nurse and instead saw the other patient that had a pending nephro consult - even though the nurse had advised him that this other patient required it more than the one he came to see.

Regardless, I take over responsibility for this patient and am told that this patient was going to be transferred from the step down area to the main ICU area... but that we needed to do a bed swap first. The nurse tells me that nephro indicated that after the u/s results came back that he wanted to be advised of the results and had left his number on the chart. So about 45min goes by and in this time the RT comes by to see one of the other patient and I comment to her that my patient's work of breathing had significantly worsened since the previous shift and I wondered whether they would benefit from some optiflow.... because they were stable on the amount of oxygen they were on but I thought would benefit from extra flow because the patient indicated that they felt like they couldn't take a deep breath. So the RT went over and talked a min with my pt and said that she thought that a ABG would be a better bet to see where they stood and sort of go from there. So the RT did that and I waited fro that result to come back.

About the same time I get the results of the u/s and the ABG and proceed to call the nephrologist. I get his voicemail and I proceed to leave one, with my direct extension. Then I wait another 30 min and don't hear anything so I call the daytime Doc who is ultimately responsible for this patient but that isn't on but does have a history of wanting to know what's going on with her patients.... so I go ahead and call her and advise her that I've called the nephrologist, left a voicemail and haven't heard back from him. I told her the results of the ABG and the u/s and she tells me that nephro is aware of the results and will be calling in orders. BTW, the ABG showed that the patient was in metabolic acidosis with a pH of 7.26 and a bicarb that I think was sitting at 5, and lactate was sitting at 7 if I remember correctly. So pt totally needs some dialysis.

Another hour goes by and I don't hear from any Docs but I get the other patient up in that time and then the nurse who's taking this patient shows up to bring her to the main ICU and I proceed to give her report, telling her evyerhing that has gone down. She then tells me that nephro called orders to our charge nurse. Which miffed me for sure. It'd the equivalent to me calling the chief of physicians to get orders. Ya I was pissed but whatever. 

Then the pt gets handed off, I wish them good luck and tell them that a few rounds of dialysis and they'll be back in business. I truely thought that at the time. 

I finish my shift and when I get to the main ICU and ask how the pt is doing, I find out that the patient crumped at like 5am and required intubation.... that their ABG showed pH at 6.97 and bicarb sitting at 2 I think.... so not good. And that the patient did NOT get a dialysis line put in after they were transferred and didn't get dialysis like they should have.

And by then it was too late.... two days later and the patient died. For no reason. If these Docs had just done their jobs.

I can't quite fathom why nephro went home after ordering that kidney u/s and not putting in a dialysis line. Having the u/s done wouldn't have changed the need for dialysis. I just don't understand it all. I don't understand how the night shift Doc put it off on the dayshift Doc, how nephro wouldn't see the sickest patient and doesn't come see the patient til the end of the day and then chooses NOT to line the patient before they leave.... or don't return when they hear that the patient is doing so bad.

This patient didn't have to die. It's so sad and really angers me. It's such a senseless death. And THIS is what gives nurses emotional burnout!